Scripts, Standard Minds, and Unjust Treatment in Healthcare Settings

Today's post comes from Gen Eickers and summarises their recent book on social scripts and their importance in healthcare:

In healthcare, epistemic and other forms of injustice are seen when patients’ lived experiences or knowledge are dismissed or undermined, resulting in unjust treatment. One key factor in this may be the role of scripts — specific normative knowledge structures that healthcare providers, for example, apply when interacting with their patients.

How do scripts work? In Scripts and Social Cognition: How We Interact with Others (Routledge, 2025), I argue that social interactions are normatively structured and that scripts, due to their reliance on social norms, provide an apt resource for explaining how we navigate the social world. Social interactions are subject to (context-sensitive) conditions of social appropriateness. 

Scripts allow us to retain extensive information about social interactions—including what is and isn't socially appropriate in each situation. That is, scripts serve as guidelines for social behavior that specify expectations about others’ behavior as a function of their identity, situational context, the cultural setting, and respective roles in that context. 

My script account, spelled out in Scripts and Social Cognition, introduces social forces (i.e., social structures, norms, and roles) to explore what structures social interaction, and to gain an understanding of whether and how scripts are related to social norms, structures, and roles. In so doing, it also sheds light on the ways that social categories, such as gender, disability, and class, impact social interaction. As social norms are stored in scripts, scripts also enshrine various biases. 

These impact our social interactions and the way we understand other people. So, scripts not only capture how to behave as someone in an institutional social role (e.g., an academic) in a framed social situation (e.g., a colloquium), but scripts also capture how to behave as a person with a specific social identity (e.g., a disabled trans man) or social group membership in a specific context. 

This accounts for the social structures in which social interactions are embedded and addresses the issue that members of less dominant social groups (such as queer, trans, Black, disabled, mad communities) are particularly subject to interactive injustice. That is, members of less dominant social groups may often find themselves to not be perceived, interpreted, or treated as equal social agents in social interactions. In this way, scripts can be considered loci of social knowledge, and sometimes they may be loci of unjust treatment.

Scripts that guide interactions in healthcare settings are often shaped by medical norms and cultural assumptions about health, which, in turn, can lead to the (further) marginalization of patients’ voices. Unjust treatment in healthcare settings may arise when the concept of a 'standard mind' is narrowly defined but universally applied. In a lot of healthcare or medical contexts, mental health and health in general is viewed through a standardized lens that excludes many subjective experiences that don't conform to norms around health, and, thus, don't fit this standard. 

When such 'non-standard minds' express their lived realities, their experiences are often disregarded. For a specific interaction within a healthcare setting this might mean: when a patient expresses symptoms that don't align with the standard scripts a healthcare professional has, the patient's account may be dismissed as unreliable, and care may be denied.

Consider, for example, a trans person seeking support by healthcare professionals in order to receive hormone replacement therapy. Healthcare professionals often rely on DSM or ICD categorizations of transness, which define transness via gender dysphoria, i.e., a negatively valenced experience, sometimes even framed as suffering. 

This dysphoria framework is shaped by norms around health and is taken to be the standard model for how trans minds work. But not all trans people experience their transness via dysphoria, or through a dysphoria framework. 

In such cases, the standard scripts applied by mental health professionals don't fit, and as a result, patients may be denied authority over their own experiences; an injustice that disproportionately affects those in multiply marginalized groups. Though I think our minds, standard or not, do have tools to do better: scripts can be combined and adjusted – for example, by gaining awareness of trans realities, different scripts may emerge about how to interact with trans people. The standard healthcare script, thus, may be complemented by scripts pertaining to gender equality.

Gen Eickers’ research is located in the philosophy of mind and emotion and the philosophy of technology as they intersect with social epistemology, social ontology, and trans and feminist philosophy. They  approach philosophical research in an interdisciplinary way, including sociology and social psychology in their work. They work primarily on scripts, social norms, social interaction, emotion, injustice, transness and gender, and social media.

Evidential Pluralism Mitigates Epistemic Injustice in Evidence-Based Evaluation

Today's post comes from Dr Alexandra Trofimov and summarises her talk at part of the Manchester Online Seminars on Evidential Pluralism titled "How Evidential Pluralism mitigates epistemic injustice in evidence-based evaluation", which will take place on the 14th of April, 2025, at 3pm BST. You can register and see the rest of the talks in the series here. 

Evidence-based evaluation aims to ensure that interventions, such as medical treatments or public policies, effectively achieve the ends at which they aim. But what kind of evidence should be considered? Orthodox evidence-based evaluation advocates an exclusive focus on comparative studies. In contrast, Evidential Pluralism advocates an inclusive approach to evidence and has been defended on the grounds that it enables more robust evaluations. In an upcoming talk, I offer a new line of argument: that Evidential Pluralism helps to mitigate epistemic injustices that result from orthodox evidence-based evaluation.

Orthodox evidence-based evaluation

Orthodox evidence-based evaluation has created an influential stereotype of ‘good evidence’ that, I argue, results in epistemic injustice.

Orthodox evidence-based evaluation is characterised by evaluation methods and evidence hierarchies that focus almost exclusively on comparative studies, especially randomized controlled trails (RCTs). This is most explicitly captured in the evidence hierarchies of evidence-based medicine, which place systematic reviews and meta-analyses of RCTs are at the top of the hierarchy, followed by individual RCTs and then observational studies. All other kinds of studies are relegated to a lower position on the hierarchy and, in practice, typically excluded from consideration. Similarly, the UK Government’s Magenta Book, which provides evaluation guidance for all Government policy and regulatory interventions, prioritises the use of experimental or quasi-experimental studies and advocates the use of other kinds of study only when these are unavailable.

Consider, for example, the controversy surrounding the effectiveness of face mask mandates during the Covid-19 pandemic. A highly influential Cochrane Collaboration systematic review that included only RCTs found no clear reduction in infections from face masks. The authors of the review concluded that, due to the various limitations of the included RCTs, firm conclusions could not be drawn. They called for further, well-designed RCTs to address the uncertainty. Many, however, mistakenly interpreted the review to mean ‘masks did nothing’. There were also dismissals of non-RCT evidence. A review that included a wide range of evidence found face masks can effectively reduce transmission. The review was criticised for being non-systematic and recommending public policies in the absence of RCT evidence.

The extent to which RCT evidence was prioritised and other kinds of evidence were devalued or dismissed is, I argue, indicative of prejudice and results in both testimonial injustice and hermeneutical injustice.

Evidential Pluralism

Addressing the epistemic injustice that results from orthodox evidence-based evaluation is crucial; it is a significant wrong that can have disastrous practical consequences. In the case of Covid-19 face masks, it led to policy delays that likely cost ‘thousands of lives’. 

Evidential Pluralism offers a solution. According to Evidential, establishing a causal claim requires establishing that the putative cause and effect are both correlated and connected by an appropriate mechanism. This, in turn, will typically require consideration of a broad range of evidence types. Evidential Pluralism takes each item of evidence on its own merits. It does not commit to pre-determined rankings of evidence or preclude certain types of studies from providing high quality evidence simply in virtue of their methodology. 

The benefits of Evidential Pluralism are illustrated in a proof-of concept evaluation of Covid-19 face mask mandates. The evaluation included a broad range of evidence types and concluded that Covid-19 face mask mandates were effective at reducing infections, hospitalisations and deaths.

By advocating a more inclusive approach to evidence, Evidential Pluralism enables more robust evaluations. It also avoids evidence being prejudicially devalued or dismissed and therefore avoids the epistemic injustice that results from orthodox evidence-based evaluation’s stereotype of ‘good evidence’.

The fact that Evidential Pluralism is able to mitigate epistemic injustice supports its adoption as a new methodology for evidence-based evaluation.

Alexandra Trofimov is a research associate in philosophy at the University of Manchester. Her research interests are in moral philosophy, legal philosophy and normative epistemology. She is currently working with Professor Jon Williamson on a Leverhulme Trust funded project ‘EBL+: New Philosophical Foundations for Evidence-Based Law’. Through an application of Evidential Pluralism to evidence-based law, the project aims to provide a new methodology for evidence evaluation to improve the effectiveness of legislative and regulatory interventions. Alexandra is also interested in improving evidence evaluation more broadly, including in public policy and public health.

Stigma, Compassion, and Recovery in Borderline Personality Disorder

Stigma plays a significant role in shaping how people with Borderline Personality Disorder (BPD) relate to both themselves and others. While much has been written about the damaging effects of stigma, its impact on compassionate acts, whether showing compassion to oneself, to others, or accepting it, remains underexplored. Yet compassion is critical for recovery, helping to foster social connection, emotional resilience, and well-being. If stigma prevents people with BPD from accessing these benefits, we need to take notice.

In a recent paper, I explore how stigma, public, institutional, and internalised, creates barriers that discourage people with BPD from engaging in compassion. These barriers are not simply personal struggles; they are embedded in societal structures and reinforced by harmful misconceptions. Addressing them is not just about promoting kindness; it is about removing a major obstacle to recovery.

How does stigma limit compassion?

Public stigma, rooted in societal attitudes, portrays people with BPD as manipulative, unstable, or even dangerous. These stereotypes do not just shape opinions, they affect how individuals with BPD are treated. Media portrayals and casual conversations reinforce the idea that they are difficult or untrustworthy, leading to social exclusion. Given that interpersonal struggles are already a core challenge for people with BPD, this exclusion only deepens their difficulties in forming meaningful, compassionate connections.

Institutional stigma is equally harmful. Many mental health professionals view BPD as a "difficult" diagnosis, leading to frustration or reluctance to treat individuals with the disorder. Service users often report their distress being dismissed as attention-seeking; having care withheld; or even being told they are beyond help. If mental health services themselves communicate that individuals with BPD are not worthy of compassion, it is not surprising that many disengage from seeking help altogether.

Then there is self-stigma: the internalisation of these negative messages. People with BPD frequently struggle with low self-worth and intense self-criticism. When the world reinforces the idea that they are undeserving of kindness, self-compassion becomes even more difficult. If you believe you are broken or unworthy, how likely are you to be kind to yourself? How likely are you to believe others’ kindness is sincere? For many, the answer is: not very.

Compassion and recovery

Yet research consistently shows that engaging in compassionate acts, towards oneself, towards others, or accepting compassion from others, can improve mental health, reduce distress, and promote recovery. So how do we dismantle the barriers preventing people with BPD from accessing these benefits?

Challenging public stigma requires changing how we talk about BPD. The harmful stereotypes surrounding the diagnosis must be replaced with a more accurate understanding. People with BPD are not manipulative or untreatable; they are individuals navigating profound emotional distress, often shaped by trauma.

Tackling institutional stigma means changing attitudes in mental health services. Clinicians need training to approach BPD with the same empathy and evidence-based care as other conditions. No one should be denied appropriate treatment because of their diagnosis.

Addressing self-stigma is perhaps the most complex but crucial step. Interventions such as compassion-focused therapy can help individuals with BPD develop self-kindness and challenge the belief that they are undeserving of care. Encouraging social connection in spaces where they feel accepted can also counteract the isolating effects of stigma.

The bigger picture

The barriers to compassion that people with BPD face are not just individual struggles; they reflect a deeper societal issue. When certain individuals are treated as less deserving of care and kindness, their path to recovery becomes exponentially harder. If we are serious about supporting people with BPD, we must take stigma seriously. More than that, we must recognise that fostering compassion, both towards and from individuals with BPD, is not just ethically important, but a necessary step in dismantling the obstacles that stand in the way of recovery.

Catrin Street-Mattox is a PhD researcher in psychology at the University of Birmingham, exploring the relationship between challenging social experiences and compassionate engagement for individuals with borderline personality disorder (BPD). Before beginning her doctoral studies, she was a specialist further education lecturer, supporting students with mental health conditions and special educational needs. Her academic interests lie at the intersection of psychology, philosophy, and mental health reform, particularly in addressing stigma and improving care systems. More about her research can be found here, and those interested in participating in her BPD study can visit bpd.cesmresearch.com.